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5.19.2016

This year the
work at a rural hospital on the edge of the Serengeti was with a team comprised
of two other herbalists, my wife Anne (gynecologist and surgeon) and two
medical students from the University of Vermont. Herbalists Molly Hagan, Annie
SewDev and myself worked on the inpatient wards, gathering daily case details
and tracking patients’ improvement; we cared for wounds and trauma in the minor
surgical theater (using only honey and botanical treatments, along with
occasional iodine, lidocaine, and lots of gauze, tape and bandages); we
harvested and processed many plants, notably Usnea, Lippia, Lantana,
Eucalyptus, Zingiber, Opuntia, Ocimum, Galium, Acacia and Aloe; and collected
samples of many more with the help of knowledgeable local folks. After a few
days there, people started to seek us out where we were processing medicine:
the guesthouse common space, where we had access to a blender, hotpot, and
storage space for herbs. They were curious to see what the herbalists were
doing, to share their thoughts on plant medicine, and to seek out our help for
a range of complaints.

Wild-harvesting adventures: Annie climbing through a tangle of vines while Molly watches

One day my
friend Joseph came over. He is a cheery man, always ready to engage in the long
greeting ritual and exchange of news. We find a way to understand each other by
making the best of our limited language skills – I get to practice my Swahili, he
pulls out a little English. The answer to the standard “Habari?” (what news?)
is always “nzuri” (good), and we began this way. But today, Joseph started to
complain that he hadn’t been sleeping very well for some time: he was restless,
waking up a lot, and not feeling refreshed. He works physically all day long,
helping to tend the hospital grounds, and his workload had been particularly
heavy as of late. I noticed an unexpected weakness in his pulse, and so we
decided to walk him over to the stand of wild ashwagandha (Withania, called
ol’asaiyet by the Maasai). He dug up a huge, gnarled, very fragrant root and we
instructed him to peel it and simmer some of the root bark in milk every
evening (hot boiled milk, rich and super-creamy, is somewhat of a staple – and
perfect for ashwagandha extraction).

Withania somnifera root

A few days
later, I ran in to Joseph as he was cutting grass. He was using a sort of long,
hooked metal blade – not quite a scythe, more of a blunt machete with a short
90 degree bend at the bottom. He would swing at the grass with this tool,
chopping and flinging off big clumps of the tall weeds that grew between the
hospital ward buildings and lawns. No wonder he was wiped out! This is tough
work – but all the grass is cut this way, week after week, all around the
hospital and the access road. Nevertheless, when I asked how he was doing, he
said his sleep was much improved, he loved the ashwagandha, and felt like he
had plenty of energy for his work. He smiled, gave me the thumbs up, and kept
swinging at the grass.

I was
surprised, the next morning, to hear the loud, choppy sound of a small engine
as I walked to our morning meeting. There was Joseph, somewhat awkwardly
pushing a gas-powered lawnmower through the tall grass left unfinished from the
day before. We smiled broadly at each other, and I thought to myself how this machine
was really going to make my friend’s work easier. Granted, it was a little
surreal to see the lawns, where the Maasai women sit every morning in the sun
airing their red, black, and purple checkered cloaks, mowed in visible lines
more characteristic of an American suburb. But still, I thought, maybe this is
progress.

Two days
later, Joseph was back at it with the machete. I gave him a puzzled look, made
a lawnmower-pushing motion with my arms, and asked “wapi?” (where?). He looked
at me with a half-grin and said, simply, “kaput” (a pretty universal word for
“broken”). I later learned that the belt had snapped, and that they had tried
to repair it, to no avail. Perhaps a replacement could be found in Arusha, over
9 hours away, but one would have to coordinate purchase and delivery somehow.
This was hard enough for medical supplies; I was skeptical that a new,
functional belt would be arriving anytime soon. And so the lawnmower sat in the
garage, like a fish out of water, its potential untapped because it was
disconnected from the supply chain it needed for survival.

It is
important to contextualize any technology. Our tools, like everything else, do
not exist outside of their environments, of the cultural and environmental
niches they occupy. One cannot simply say “a lawnmower is great at cutting
grass, let’s get one” and use it regardless of where the grass is growing.
Joseph’s circumstances and environment are as important to the function of the
lawnmower as is the gasoline it uses. Technology’s impacts and effectiveness
cannot be measured in absolute terms: like anything else, the relationship and
connections that technology has in any given situation have as much to do with
how well it will work as the nuts and bolts of the technology itself. Sometimes
tech is so powerful that it changes its environment: witness the widespread
adoption of cell phones around the globe. Commerce has changed as a result.
Maasai bomas (dwelling communities) install small solar panels for the sole
purpose of charging their phones, so they can send funds back and forth and
connect with friends and family. Still, the way the cell phone works in rural
Tanzania is very different than how it works in America: even if a technology
is powerful enough to alter its new environment, its expression is still bound
to its context. Technology must be effectively integrated into its cultural and
environmental context to be successful, sustainable, and non-damaging.

Nowhere else
is this more evident than in global development work. If our goal is to
increase capacity, resilience, and sustainability in the developing world (or
anywhere, really), we must consider context when discussing the application of
technology. Consider the example of water: in East Africa, year-round water
supply is essential. In the 1980s, when the country was still stable, my father
(a geologist and soil engineer) worked in Somalia digging wells in desert
areas, so local communities could have water security. I remember him (and my
mother) being gone during all of Summer vacation. When he returned, he told
stories of the fancy wells the Italian government had dug, only to have them
break and be left, abandoned, after a few months’ use. He worked with local
engineers to develop a pump system that relied on donkeys walking in circles,
strapped to a central, rotating piston. Primitive? Perhaps. But much more
effective and resilient in the context of East Africa. Here we had a merging of
the modern and the ancient: sophisticated geological surveys found the water,
drilling rigs accessed it, and donkeys kept the water flowing. This is
integrated technology.

While
working on wound care and support at the Wasso district hospital, the team of
herbalists was confronted with this reality every day. There are old, broken
pieces of Western medical tech littered throughout the hospital: rusted, broken
leg braces; dysfunctional surgical lights with no lightbulbs; ventilator bags
with tape over the cracking plastic. So when there is an issue, we must find a
solution not by bringing our technology (be it essential oils and tinctures, or
laparoscopic surgery equipment), but by developing integrated technologies.
Perhaps the best example of this was the improvised traction splint we made for
a woman whose femur had been completely broken when she was hit by a car.
Hospital staff had applied a makeshift cast on the leg, but it didn’t even come
up to the femur fracture. And now, because there are no orthopedic surgeons in
Wasso, they were suggesting she get into a Land Rover and travel 9 hours to
Arusha, the nearest facility that could properly set her bone. Now, the femur
is the longest bone in the human body. It keeps the powerful quadriceps muscles
stretched out, ready to help us walk, run and jump. But when it’s broken, the
quads contract back, pulling the jagged edges of the fracture until they
overlap and dig into muscle tissue, ripping vessels. Patients can lose huge
amounts of blood inside their leg, risking compartment syndrome and even death.
I’ve been on the road to Arusha – “bumpy” is a gross understatement. What this
woman needed was traction: something to pull her ankle and pelvis apart with
enough strength to counterbalance the quad’s contraction, so the two pieces of
the femur would remain in line and separated, preventing them from destroying
tissue.

When we made
this suggestion, staff laughed. “You cannot hold traction for the entire ride
to Arusha,” they exclaimed. And they were right: the force needed to pull back
against the quad requires two people, one at the ankle and the other at the
armpits, pulling with all their might. What she needed was a traction splint: something
to hold the tension and stabilize the femur at the same time. Of course, no
such device exists at Wasso hospital. So, remembering my wilderness first
responder training, we decided to make one. Molly, her Maasai sime (long
machete) in hand, went out to hack off yellow-bark acacia limbs: one for the outside
of the leg, up past the pelvis, and a shorter piece for the inside of the leg.
She also fashioned a cross-member for the bottom of the splint and a smaller, “twisting
stick” to increase and secure traction. I started tearing up a bedsheet into
long strips to lash the splint together. Annie stayed with the patient and
helped explain our plan to the hospital staff, who were now gathering around,
very interested.

Getting ready to apply traction. Molly at the shoulders, Annie and I get the splint ready.

We lashed
the outer and inner sticks to the cross-member (which was about 6 inches under
the patient’s heel), padded the tip of the inner stick so it could rest
comfortably in the crotch, and loosely tied a strip of bedsheet around her
ankle. This strip was also secured to the cross-member, and the “twisting stick”
slid between the loop just under the heel. Then, giving it all we had, Molly
and I applied traction, pulling the femur bone apart so that the heel almost
touched the cross-member while Annie turned the twisting stick to make sure
there was no slack between the heel and the cross-member of the splint. Annie
finished by tying the two sticks together, under the knee, above and below the
fracture, and then placing a final belt around the outer stick and across the
woman’s pelvis. Molly and I released traction – and the leg didn’t move.
Success.

Splint ready for traction

We remarked
to ourselves that we would probably never make another improvised traction
splint. But never say never: just two days later, a seven-year-old boy came in
to minor theater, having been trampled by an elephant. He was moving in and out
of consciousness, and showed abrasions on his head, chest, and arms. But his
pupils reacted, and when he was conscious, he could respond to commands well.
So what concerned us most was the right leg, which was floppy and bleeding at
mid-thigh from a compound femur fracture. We moved quickly, repeating our work
(but this time on a smaller scale). After getting everything ready, we applied
traction. Dr. Anne remarked that she heard a slight “pop” as the leg extended
and the femur moved back into position. We secured the splint, and the boy was
moved to the intensive care ward to await transfer to Arusha.

After applying traction and securing: heel is closer to cross-member

In America,
you can buy fancy traction splints. They are amazing, quick and
super-effective. Our work was probably not as effective, but it did the job
(especially considering the long car ride ahead for both patients). And it was
simple enough to replicate: hospital staff can make similar splints now, and
improve outcomes for those who come through Wasso. Similarly, hospital staff
now uses honey and herbal treatment for wound care, and after extensive
research this time around, we look forward to continuing to enhance the hospital’s
portfolio of low-cost, effective herbal interventions that come from the local
environment. These are sustainable, improve the hospital’s capacity to help
others, and build independent capacity rather than dependence on Western
intervention. These are integrated technologies.

Yet another
example of success building hospital capacity with integrated technology came
from our partners, Dr. Anne Dougherty and medical students Sabrina Bedell and
Melanie Ma. They followed pregnant women in the hospital, screened for
gynecologic complaints, and performed surgery when necessary (using old-school,
open laparotomy). They traveled to outreach clinic to perform prenatal checks
and vaccinate babies against polio and other diseases. Beyond all this
(including middle-of-the-night work on complicated deliveries), they worked a
whole week of 16+ hour days screening women for breast cancer, HIV, and
cervical cancer. In so doing, they also helped establish and cement a cervical
cancer screening and treatment program at the hospital where none existed
before.

Dr. Anne in outreach clinic, showing a mom her baby using portable ultrasound

Cervical
cancer is a huge problem in Tanzania. While in the US every year there are 7.5
cases out of 100,000 women, in Tanzania there are 54. Out of the 7,300 cases
diagnosed in Tanzania in 2012, over 4,200 died. It is the leading cause of
cancer-related deaths in Tanzania for women aged 15-44. One of the biggest reasons for the differences
between the US and Tanzania is essentially an issue of integrated technology:
in the US, frequent screenings and the pap smear have made early detection and
treatment easy and effective. An abnormal pap brings a call from your
physician, and you can decide on a range of treatment options, from herbal and
nutritional strategies to LEEP procedures and beyond (depending on the nature
of the problem), and come back for re-testing. But this technology just doesn’t
work in East Africa: first of all, you need a pathology lab to analyze pap
smears (there is one, but it’s nine hours away in Arusha). Secondly, after
getting results, you need to find a way to inform the women, and get them to
come back to the hospital (often hours, if not days, away) for treatment. This
is difficult. As a result, if women are screened at all, they are often lost to
follow-up and worrisome screening results are left untreated – until they
return to the hospital with persistent vaginal bleeding and weight loss from
advanced, invasive cancer. Our Western technology fails in this case, because
the context in East Africa is so vastly different from the context in the US.

The medical
team relied on a simple, yet surprisingly effective combination of screening
and treatment to circumvent these issues. First, the cervix is swabbed with a
solution of simple white vinegar (available everywhere). After one minute, the
cervix is examined. Any white lesions indicate a potential issue with cervical
cells, most likely from dysplasia or early cancerous changes. If such lesions
are found, staff performs cryotherapy: using compressed carbon dioxide gas, a
metal tip is super-cooled and used to freeze off the top layer of cervical
cells. The tip is relatively inexpensive, and can be re-used forever; the
compressed CO2 can be flown in from Arusha and allows for between 25 and 30
cryotherapy treatments. This see-and-treat model completely bypasses the
followup problem. And in the end, it saves lives (to read more, see this WHO report). Dr. Anne and her team screened over 300 women, treated almost 30 for
pre-cancerous lesions, identified 6 others who needed more advanced treatment
in Arusha, and discovered one case of invasive cancer. This last case was sad
to hear about – but now, this screening program is established in Wasso, and
such cases will hopefully be prevented in the future. This see-and-treat model
may not be the gold standard in the US, but it is much more effective in East
Africa. It builds sustainable capacity. It is a well-integrated technology.

In all these
examples, we see a few common threads. There is an awareness of the context in
which the technologies are being applied: what’s the nature of the problem?
Where does it live? What are the social, cultural, and environmental factors at
play? There is also a focus on empowering the system, rather than building
dependence. When Western resources are used, they are often just catalytic –
the technology is meant to stand on its own. Finally, the solutions are built
with resilience in mind: in the parlance of systems theory, all the examples
described increase the system’s capacity for “disturbance rejection”.
Integrated technologies are like herbal adaptogens: nutritive, gentle, familiar
ways to enhance adaptability and build sustainable energy.

I would
argue that herbal medicine is a quintessential example of an integrated
technology. It shows awareness of context, strives for empowerment rather than
dependence, and increases resiliency (not only of the person taking the herbs,
but also of the community that embraces herbal medicine). And to push a little
further, let me suggest that context, in the case of medicine, means more than
culture and environment: it means the ecosystem of diseases with which we
struggle. Modern tech medicine sometimes loses awareness of this facet of context:
cardiovascular disease, for example, is as different from acute infection as
the Western woman is from the Maasai bibi. How can we develop truly integrated
technologies for handling the chronic diseases of our culture? Part of the
answer lies in letting go of labels like “advanced” and “primitive”. Let us
think more about effectiveness, rather than pursuing new technology for its own
sake. We may find that the plants that have evolved side-by-side with us for
hundreds of thousands of years can help create a more sustainable, effective,
and resilient system for medical care. In so many ways, and on so many levels, consuming
plants is an exquisitely fine-tuned integrated technology. I am grateful to the
people of Wasso, and the Wasso phytotherapy project, for reminding me of this
with such simple clarity.